Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment Week 9 SOAP NOTE Doris Ofodile Walden University Nurs 6512 Advanced Health Assessment & Diagnostic Reasoning Dr Kristin Curcio July 31st, 2022 Patient Initials: T.J Age: 28 Gender: Female SUBJECTIVE DATA: Chief Complaint (CC): " I came in because I'm required to have a recent physical exam for the health insurance at my new job" History of Present Illness (HPI): Miss Jones is currently employed by Smith, Steven, Stewart, Silver & Company. Before she begins work, a pre-employment physical must be completed. Despite having a history of type 2 diabetes, in which she is able to control it by taking metformin, dieting, and doing physical activity. For the past 4-5 months, she has been compliant with metformin. By eating yogurt, Metformin has no longer caused any side effects for her. The last time she saw a doctor was for her gynecology appointment four months ago in which the doctor prescribed oral birth control pills to her after she was diagnosed with the polycystic ovarian syndrome. Although, according to her, she is in good health and does not have any acute health issues, or stressful events, and is looking forward to starting her new job. Medications: Metformin 850mg PO BID, the last dose taken this morning. Fluticasone propionate (Flovent) was 110 milligrams twice daily.( taken last in Albuterol (Proventil) 90mcg 2 puffs every four hours PRN.( taken three months ) Drospirenone/ethinyl estradiol (dosage unknown). It was taken this morning. Tylenol 500 mg PO PRN for headache, medication was taken last week. Ibuprofen 600mg PO TID PRN to alleviate period cramps, was taken six weeks ago. Zantac was taken for GERD (completed) Tetracycline was taken because of acne (completed) Allergies: Miss Jones is allergic to penicillin which causes an allergic reaction characterized by hives and a rash. She is also allergic to cats and dust which triggers an asthma attack causing her to itch, wheeze and sneeze. She denies allergic reactions to latex and foods. Past Medical History (PMH): During her second and a half years of life, Miss Jones was diagnosed with asthma. Her medication regimen includes Proventil and Flovent. A diagnosis of diabetes was made at the age of twenty-four. Metformin is the medication she uses to manage her diabetes, but she had trouble complying because she had side effects like gassiness, which was later relieved with yogurt. As a result, she is better able to monitor her blood sugar levels daily, which last read at 90. The patient also reports losing 10 pounds in four months. Also, she reported that she slipped and hit her right foot, resulting in a healed wound. At the age of 28, she was diagnosed with the polycystic ovarian syndrome which she manages by taking birth control pills. Miss Jone’s menstrual cycle flows for five days and is regular. No Sexually transmitted diseases or pregnancies have been reported. At 38.

1. Digital Clinical Experience: Comprehensive (Head-to-Toe)
Physical Assessment
Week 9 SOAP NOTE
Doris Ofodile
Walden University
Nurs 6512
Advanced Health Assessment & Diagnostic Reasoning
Dr Kristin Curcio
July 31st, 2022
Patient Initials: T.J Age: 28 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): " I came in because I'm required to have
a recent physical exam for the
health insurance at my new job"
History of Present Illness (HPI): Miss Jones is currently
employed by Smith, Steven, Stewart,
Silver & Company. Before she begins work, a pre-employment
physical must be completed.
Despite having a history of type 2 diabetes, in which she is able

2. to control it by taking metformin,
dieting, and doing physical activity. For the past 4-5 months,
she has been compliant with
metformin. By eating yogurt, Metformin has no longer caused
any side effects for her. The last
time she saw a doctor was for her gynecology appointment four
months ago in which the doctor
prescribed oral birth control pills to her after she was diagnosed
with the polycystic ovarian
syndrome. Although, according to her, she is in good health and
does not have any acute health
issues, or stressful events, and is looking forward to starting her
new job.
Medications: Metformin 850mg PO BID, the last dose taken this
morning.
Fluticasone propionate (Flovent) was 110 milligrams twice
daily.( taken last in
Albuterol (Proventil) 90mcg 2 puffs every four hours PRN.(
taken three months )
Drospirenone/ethinyl estradiol (dosage unknown). It was taken
this morning.
Tylenol 500 mg PO PRN for headache, medication was taken
last week.
Ibuprofen 600mg PO TID PRN to alleviate period cramps, was
taken six weeks ago.
Zantac was taken for GERD (completed)
Tetracycline was taken because of acne (completed)
Allergies: Miss Jones is allergic to penicillin which causes an
allergic reaction characterized by
hives and a rash. She is also allergic to cats and dust which
triggers an asthma attack causing her to
itch, wheeze and sneeze. She denies allergic reactions to latex
and foods.

3. Past Medical History (PMH): During her second and a half
years of life, Miss Jones was
diagnosed with asthma. Her medication regimen includes
Proventil and Flovent.
A diagnosis of diabetes was made at the age of twenty-four.
Metformin is the medication she uses
to manage her diabetes, but she had trouble complying because
she had side effects like gassiness,
which was later relieved with yogurt. As a result, she is better
able to monitor her blood sugar
levels daily, which last read at 90. The patient also reports
losing 10 pounds in four months. Also,
she reported that she slipped and hit her right foot, resulting in
a healed wound.
At the age of 28, she was diagnosed with the polycystic ovarian
syndrome which she manages by
taking birth control pills. Miss Jone’s menstrual cycle flows for
five days and is regular. No
Sexually transmitted diseases or pregnancies have been
reported.
At 38-year-old, she was diagnosed with hypertension; Exercise
and diet helped normalize her
blood pressure. Blood pressure medication is not needed by the
patient.
At the age of 28, myopia was diagnosed, and prescription
glasses were needed. No recent
hospitalization.
Past Surgical History (PSH): No history of surgery.
Sexual/Reproductive History: Miss Jones is a single woman
without children. Denies pregnancy
and Sexually transmitted diseases. Reports two years without

4. sexual activity.
Personal/Social History: Currently, Miss Jones lives with her
mother and sister in a single-
family house but announced moving into an apartment with her
boyfriend. She does not smoke,
vape, or use any illegal drug but drinks occasionally with
friends which consist of diet coke and
rum. There is currently no sexual activity between her and her
boyfriend. She reports that if she
becomes sexually active, she will use a condom. Miss Jones
enjoys hanging out with her friends by
going to bible study. She soon plans on starting a book club.
Her exercise regimen includes 30 to 45-minute walks five times
a week and weekly swimming
sessions with her sister.
Miss Jones is a recent graduate working as an accounting clerk
at a new job. When it comes to her
eating habits she mainly consumes food low in carbs but is not
cautious when it comes to her
sodium intake. Her breakfast consists of smoothies, yogurt, and
eggs on toast, lunch consists of
leftover dinner and wheat bread, and dinner consists of chicken
or fish, vegetables, rice, and
quinoa. Her daily intake of water is typically around 4-5
glasses.
Health Maintenance: When going outside, the patient uses
sunscreen. Additionally, she always
wears a seatbelt while driving. Four months have passed since
her last pap smear in which the
results were negative. An optician prescribed reading glasses to
the patient three months ago. Ms.
Jones reports feeling safe at home.
Immunization History: During her childhood and in college, she

5. received the tetanus shot and
other required vaccinations. According to her, she did not
receive a flu shot.
Significant Family History: The father died in a car accident
when he was 58 years old. He was
diagnosed with hypercholesterolemia, hypertension, and type 2
diabetes.
There is also a history of hypertension and
hypercholesterolemia in her mother of 50 years.
Her 27-year-old brother is obese.
Her 14-year-old sister suffers from asthma.
At the age of 80, her maternal grandfather died from a heart
attack and also had a history of
hypercholesterolemia and hypertension.
At the age of 73, her maternal grandmother had a stroke and
died, Also had a diagnosis of
hypertension and hypercholesterolemia.
At the age of 65, her paternal grandfather died from
complications of colon cancer. A diagnosis of
hypertension and type 2 diabetes was made for him.
At the age of 82, her paternal grandmother was diagnosed with
hypertension and
hypercholesterolemia.
An uncle of my paternal line, age unknown, is an alcoholic.
There is no history of mental illness in the family.
Review of Systems:
General: T.J. reports being excessively healthy. Over the past
couple of months, she has lost 10
pounds. Her energy and stress levels have improved.
HEENT: Denial of headaches and tenderness of the scalp and

6. report no head injury reported.
Denies having pain in the eyes although complains of blurred
vision when not wearing corrective
lenses. Denies hearing loss and ear pain. Denies losing her
smell or having rhinorrhea. Denies
having mouth sores or dental problems but attends dental visits.
Denies having a sore throat or
difficulty swallowing. Denies feeling pain in the neck.
Respiratory: Denies breathing difficulties. Denies experiencing
asthma or dyspnea. Reports that
three months ago, she had her last asthma attack.
Cardiovascular/Peripheral Vascular: Denies palpitations, chest
pain, or pressure in the chest.
Gastrointestinal: The patient reports that her appetite is normal.
Denies symptoms such as nausea,
vomiting, constipation, and diarrhea. There has been no change
in bowel movements. Since a few
months ago, there has been no heartburn or symptoms.
Genitourinary: Denies having any symptoms of urinary
incontinence. Neither hematuria nor
flank pain is reported. There are no reports of vaginal discharge
or itching.
Musculoskeletal: Denies joint and muscle pain. She denies
feeling pain in her back, legs, or arms.
There were reports of back pain a week ago. The pain has gone
away after stretching and using
heat and ice packs.
Neurological: Neither headaches, dizziness, nor lightheadedness
have been reported. There were
no syncopal episodes or loss of sensation.
Psychiatric: Denies HI and SI. Affirms that she does not have
depression and anxiety.
Skin/hair/nails: There has been improvement in her facial acne
and the discoloration on her neck
has faded.

7. OBJECTIVE DATA:
Physical Exam:
Vital signs: Temperature 37.2 C; RR 15; HT 5'7, Pulse Ox 99%
WT 90kg, HR 78; BMI 31, BP
128/82;
General: Ms. Jones has a good sense of direction and is alert.
The patient is seated upright on the
examination table. Her grooming and clothing are appropriate
for the weather. It does not appear
that she is in distress.
HEENT: There are no masses or lesions on the scalp, and the
hair is distributed evenly. There is
no injury to the head and it is normocephalic. A uniform
distribution of eyebrows and lashes. The
sclera is white and the eyes are clean. There is a bilateral
PERRLA and pink conjunctiva. It was
noted that the right eye had cotton bodies and retinopathic
changes. Hemorrhages were not
observed. The Snellen test shows 20/20 vision bilaterally in
both eyes with a corrective lens. The
mucosa of the mouth is moist and pink. There were no mouth
sores or dental problems observed. A
midline uvula and gag reflex are present. Moisture and pinkness
are present on the tongue. There is
no goiter or nodule on the thyroid. The TM is pale gray in color
and intact. There are no signs of
infection. Heard bilaterally during the whisper test. The nasal
mucosa appears to be moist and
pink. When palpated, the sinuses of the face are not tender.
Neck: Refutes having any neck pain or problems.
Chest/Lungs: There are no signs of acute distress. An even and
unlabored breathing pattern is
present. When auscultated, there are clear breath sounds. No

8. sounds of adventitious breathing were
heard. Throughout the lobes, there is a resonance on percussion.
Based on spirometry, the FVC
was 1.78 L, the FEV1 was 1.549 L, and the FEV1/FVC ratio
was 87 - 88%.
Heart/Peripheral Vascular:
S1 and S2 do not have murmurs, gallops, or clicks. Heart rate
appears regular. There is no bruit
bilaterally in the carotid artery. A PMI is present at the fifth
intercostal space along the clavicular
line. Non-displaced PMI with no heaves or lifts. All extremities
have 2+ peripheral pulses. All
extremities have a capillary refill time of less than 3 seconds.
Edema not present
Abdomen: There are no tenderness scars on the abdomen. It is
symmetrical and does not appear to
have a mass. Hair observed on the pubic area. Protuberant
abdomen. In all four quadrants, bowel
sounds are normoactive. There is softness in the abdomen. The
tympanic sound can be heard on
the percussion. There is no tenderness on palpation of the CVA.
Organomegaly is not present. The
mass was not palpable. Palpable kidneys with no mass after
deep operation. On percussion, the
liver measures 7cm MCL. The liver is 1 cm below the RCM.
Genital/Rectal: On hold for this visit.
Musculoskeletal: All ranges of motion observed. Movement is
not painful. The muscle
In all extremities, strength is 5/5. All regions have DTRs of 2+.
Observed neuropathy in the plantar
of feet. There was no evidence of deformity.
Neurological:

9. Stereognosis and graphesthesia are normal. All extremities have
DTRs of 2+.
Hands alternate equally in both directions. Foot plantar
neuropathy was observed.
Skin:
On the face, acne vulgaris is observed. Under the nose, facial
hair is observed. At her neck, she
was found to have acanthosis nigricans. Nail appears to be
normal.
Diagnostic results:
ASSESSMENT:
● The following lab tests may be recommended: Broad Thyroid
Panel; Essential Nutrients:
iron/ferritin, vitamin D, vitamin B12, magnesium; Complete
Metabolic Panel and
Complete Blood Count.
Diabetes mellitus, renal failure, and anemia are some of the
conditions that can be detected
by blood tests. The best time to order a blood test is after a
complete history and physical
examination indicate questionable symptoms (Shaked et al.,
2019).
● The following metabolic markers are measured: hemoglobin
A1c, fasting glucose, insulin,
and lipid profile.
There are several cardiometabolic disorders included in the
metabolic syndrome (MetS),
including central obesity, high triglyceride levels, high blood
pressure, low HDL
cholesterol levels, and hyperglycemia (Li et al., 2018). The
results of this test will reveal
abnormalities and assist the provider in making health
recommendations.

10. ● Inflammatory markers: homocysteine hsCRP,
Primary care physicians regularly use inflammation markers
such as C-reactive protein
(CRP), erythrocyte sedimentation rate (ESR), and plasma
viscosity (PV) to diagnose and
observe inflammatory illnesses such as infections, autoimmune
diseases, and malignancies
(Watson et al., 2019).
● Testing of the urine for drugs and alcohol (if requested by the
employer).
Albumin levels are determined by a urine test. A protein called
albumin can leak into the
urine when kidney function is impaired (Niddk.nih.gov., 2016).
In diabetics, urine albumin
creatinine ratios (UACRs) detect abnormal protein levels and
should be checked annually
(Willison et al., 2016).
● Vaccine titer test
A decrease in antibodies is revealed by this test. It is imperative
to link the assay's results to
a clinical interpretation in order to determine an individual's
susceptibility to infection
(Charlton et al., 2016).
Plan:
The patient will be given the results of the lab work and a list of
immunizations for him or her to
take to work.
Vaccine booster shots are recommended if a decrease in
antibodies is detected based on the

11. vaccine titer test.
Education: If you experience shortness of breath, chest pain,
syncope, nausea/vomiting, or
lightheadedness, call 911 or go to the emergency department.
Continue to take medications as prescribed. Consult your
provider before stopping medication.
A morning and night blood pressure check is recommended.
Each morning, weigh yourself on the same scale before eating
breakfast.
Record your daily caloric intake in a journal.